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Argus II Retinal Prosthesis Implantation Using Three-Dimensional Visualization System The Argus II retinal prosthesis system (Argus II) (Second Sight Medical Products, Inc, Sylmar, CA) was approved by the Food and Drug Administration in 2013 for patients with retinitis pigmentosa and visual acuity of bare light perception or worse.1 It is currently implanted in qualified patients in the United States and worldwide with more than 300 implants performed up to date. Our center has performed a total of 13 cases. In this study, we describe our experience with Argus II Retinal Prosthesis implantation using a three-dimensional (3D) visualization system (Ngenuity; Alcon, Fort Worth, TX) in three consecutive patients. This system consists of a 3D stereoscopic, highdynamic range digital video camera with image displayed real time on a flat-panel 4K 3D organic light-emitting diode (OLED) display. There is no additional light (or energy) delivered by the system for visualization or image capture.2 Three consecutive Argus II surgeries were performed using a 3D visualization system (see Video 1, Supplemental Digital Content 1, http://links.lww. com/IAE/A906) mounted on a Lumera 700 (Carl Zeiss Meditec Jena, Germany) surgical microscope. The Resight viewing system and Rescan 700 for intraoperative optical coherence tomography (OCT) were used in all cases with integration of the OCT signal into the 3D display. The Constellation system (Alcon) was used for vitrectomy. Mean patient age was 74 (range 68–81). All three were men. The mean axial length was 23.9 mm (range 23.6–24.2). The mean surgical time was 310 minutes (range 192– 324). In comparison, the surgical time of the other 10 patients was 236 minutes (range 182–301) (P = 0.12). Two cases required concurrent phacoemulsification, one of which was performed using a standard viewing system and required the use of a fragmatome, and the second was performed using the 3D viewing system and was uneventful. A case that did not require cataract removal was 192 minutes in duration. Of note, a single case of 324 minutes was due to intraoperative complication unrelated to 3D visualization system. We found that 3D visualization worked well on all steps of the Argus II implantation surgery (see Video 1, Supplemental Digital Content 1, http://links.lww. com/IAE/A906). At no point, there was a need to convert from 3D viewing to standard microscope viewing. The Argus surgery involves implantation of external and internal components. A 360° limbal conjunctival peritomy is followed by isolating rectus muscles and passing a silicone band, so that the receiving coil sits under the lateral rectus and in the inferotemporal quadrant, and the electronics case is positioned in the superotemporal quadrant. The ends of the silicone band are secured with a silicone sleeve in a similar fashion to a scleral buckle, and the band, coil, and electronics case are sutured to the sclera. Then, a standard 25-gauge vitrectomy is performed with careful depression over the superotemporal sclerotomy site. A 5.2-mm sclerotomy is created in the superotemporal quadrant tangent to the limbus. The electrode array is inserted into the mid vitreous cavity using 20-g end-grasping forceps. The sclerotomy is closed around the cable traversing the eye wall using prolene sutures. After enlarging the nasal and temporal sclerotomies to accommodate the tacking instrument and 20-g end-grasping forceps, a bimanual technique with chandelier illumination is used to place the array on the retina and to tack it using a retinal tack. All sclerotomies are sutured and confirmed to be watertight. Tutoplast allograft is secured over the array cable, electronics case suture tabs, and receiving coil From the Vitreoretinal Service, Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio. Presented in part at the Annual Vit Buckle Society Meeting, Miami, FL, March 24, 2018. AVR: Allergan (C), Alcon (C) and Zeiss (C), JPE: Genentech (R, C), Regeneron (R), Thrombogenics (R, C), Leica (P, C), Zeiss (C), Alcon (R, C), Roche (C), and Santen (C), and M. DeBenedictis: Second Sight (C). The remaining authors have no any financial/ conflicting interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.retinajournal.com). The authors had total control of all aspects of this surgical technique report including design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Reprint requests: Aleksandra Rachitskaya, MD, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/i32, Cleveland, OH 44106; e-mail: [email protected] Scan code to view VIDEO